This document discusses spontaneous bacterial peritonitis (SBP). It recommends that a diagnostic paracentesis be performed on all patients with ascites to test for SBP. SBP should be treated empirically if the ascitic fluid polymorphonuclear leukocyte count is ≥250 cells/mm3. Albumin therapy is recommended for SBP patients with renal dysfunction. The document differentiates between spontaneous and secondary SBP, noting that secondary SBP requires surgical management. It also provides guidance on SBP prophylaxis.

1. Noon Conference
Kristen Beck

2. © 2016 Virginia Mason Medical Center
SBP: Clinical manifestations
• Suspect SBP if:
Fever
Abdominal pain
AMS
Hypotension
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SBP: Clinical manifestations
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SBP: Diagnosis
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• Who needs a diagnostic para?
 EVERYONE you suspect
 ANYONE with ascites admitted for
other reasons
 Even if low clinical suspicion  should
still test
 Physician clinical suspicion 42% sensitivity
 Study: SBP diagnosed in 12% with low
clinical suspicion

5. © 2016 Virginia Mason Medical Center
SBP: Diagnosis
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• Who needs a diagnostic para?
 EVERYONE you suspect
 ANYONE with ascites admitted for
other reasons
 Even if low clinical suspicion  should
still test
 Physician clinical suspicion 42% sensitivity
 Study: SBP diagnosed in 12% with low
clinical suspicion

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Importance of paracentesis
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 Diagnostic para decreases mortality!
 Of 17,000 pts (Orman 2014) with
cirrhosis and ascites who got para:
 In-hospital mortality decreased 24%
 OR 0.55
 In-hospital mortality lower among those
who got early paracentesis

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SBP: Diagnosis
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 Ascitic PMNs ≥250 cells/mm3
 Positive ascites cultures
 Other causes of peritonitis excluded
BUT:
 Treat empirically if PMNs ≥250
cells/mm3

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Spontaneous vs secondary
bacterial peritonitis
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 Secondary BP: Positive ascites
culture and PMN ≥250 with surgically
treatable intraabdominal source
 Perforation peritonitis
 Perforated peptic ulcer
 Non-perforation peritonitis
 Ex: perinephric abscess
 Rare (Less than 1/20)
 Clues: polymicrobial infection

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Secondary bacterial peritonitis
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Runyon Criteria:
●Total protein >1 g/dL (10 g/L)
●Glucose <50 mg/dL (2.8 mmol/L)
●LDH >the upper limit of normal for
serum

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Secondary bacterial peritonitis
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Runyon Criteria:
●Total protein >1 g/dL (10 g/L): <0.8
●Glucose <50 mg/dL (2.8 mmol/L)
●LDH >the upper limit of normal for
serum: LDH 81 (normal 100-190)

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Spontaneous vs secondary
bacterial peritonitis
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• Mortality ~100% if Secondary BP
treated with antibiotics alone
• Unnecessary ex-lap in SBP has shown
~80% mortality

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SBP: Treatment
• Antibiotics
• 3rd Gen cephalosporin
• Ciprofloxacin if allergy (but less
effective?)
• Discontinue beta blockers
• Increased mortality
• Increased rates of HRS
• Increased hospital LOS
• Albumin?
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SBP: Treatment
• Albumin therapy
• If renal dysfunction
• Cr > 1.0
• BUN >30
• Total bilirubin >4
• 1.5g/kg within 6 hrs of diagnosis
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SBP: Prophylaxis
• Who needs SBP Prophylaxis?
 History of SBP: Outpatient Bactrim
DS or fluoroquinolones (prolonged)
 Inpatients with ascites protein <1 (or
<1.5 if hospitalized for other reason):
Bactrim DS or fluoroquinolones while
inpatient
 Cirrhosis and GIB: CTX and then
Bactrim or FQ once tolerating PO for
7 days
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MKSAP Question
A 47-year-old woman is evaluated in the emergency department
after vomiting bright-red blood. She has alcoholic cirrhosis with
ascites, which has been well controlled with diuretics. She has had
jaundice and intermittent confusion for the past month. She has not
consumed alcohol in the past 11 months. Her medications are
spironolactone and furosemide, and octreotide was begun in the
emergency department.
On physical examination, temperature is 36.8 °C (98.2 °F), blood
pressure is 72/54 mm Hg, pulse rate is 112/min, and respiration rate
is 20/min; BMI is 26. She is confused. Scleral icterus, jaundice, and
spider angiomata over the chest are noted. The left lobe of the liver
is firm and is palpated 3 cm below the costal margin. There is no
abdominal pain or flank dullness.
Laboratory studies reveal a hemoglobin level of 8.7 g/dL (87 g/L).
Intravenous fluid resuscitation is initiated.
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MKSAP Question
Which of the following is the most appropriate next
step in management?
a. Antibiotics
b.Non-selective β-blocker
c. Transjugular intrahepatic portosystemic shunt
placement
d.Upper endoscopy
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MKSAP Question
Which of the following is the most appropriate next
step in management?
a. Antibiotics
b.Non-selective β-blocker
c. Transjugular intrahepatic portosystemic shunt
placement
d.Upper endoscopy
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18. © 2016 Virginia Mason Medical Center
Summary
• Get a diagnostic para on patients
with ascites
• Treat SBP empirically if PMN ≥250
• Albumin if renal dysfunction
• Rule out need for surgical
management
• SBP prophylaxis on patients with
history of SBP, ascites protein <1, or
GIB
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